Can Hemorrhoidectomy Be Performed During Lateral Sphincterotomy?
Yes, hemorrhoidectomy can be safely performed during lateral internal sphincterotomy, and this combined approach actually reduces postoperative complications compared to staged procedures. The evidence strongly supports concurrent treatment when both conditions require surgical intervention.
Evidence Supporting Combined Surgery
The addition of lateral internal sphincterotomy to hemorrhoidectomy significantly improves outcomes by reducing postoperative pain at 12,24, and 48 hours, decreasing bleeding and urinary retention rates, and lowering long-term complications including anal stenosis and recurrent fissures 1. In a study of 200 patients, those who underwent combined LIS with Milligan-Morgan hemorrhoidectomy experienced significantly less postoperative pain (p<0.001) and fewer complications than hemorrhoidectomy alone 1.
When Combined Surgery Is Indicated
Chronic anal fissure (>8 weeks) with symptomatic grade 3-4 hemorrhoids requiring surgical intervention should be addressed in a single operative setting 2, 1
Hemorrhoids with posterior subsidiary packet and internal sphincter hypertonia represent an ideal indication for combined posterior sphincterotomy with hemorrhoidectomy 3
Relapsed hemorrhoids with postoperative anal stenosis can be safely treated with combined sphincterotomy and hemorrhoidectomy 3
Surgical Approach and Technical Considerations
Perform lateral internal sphincterotomy first, followed by conventional excisional hemorrhoidectomy using either Milligan-Morgan (open) or Ferguson (closed) technique 2, 1. The sphincterotomy should be "minimal cutting" to reduce incontinence risk, especially since hemorrhoidectomy itself carries up to 12% risk of sphincter defects 2.
Preoperative anorectal manometry is essential to modulate the sphincterotomy depth, avoiding inadequate sphincter division (residual hypertonia) or excessive division (continence problems) 3
Open technique of lateral sphincterotomy can be safely employed with hemorrhoidectomy in properly selected patients 4
Avoid posterior midline sphincterotomy when possible, as lateral sphincterotomy shows superior outcomes with lower complication rates 3, 5
Expected Outcomes and Complications
Combined surgery shows excellent results with acceptable complication profiles:
Postoperative pain: Significantly reduced with LIS addition (12% vs 42-50% requiring rescue analgesia) 5
Hospital stay: 90-96% of patients discharged within 24 hours when LIS performed alone or with minor procedures 5
Urinary retention: 2.6% with LIS alone, 5.3% when combined with hemorrhoidectomy 4
Gas incontinence: Transient in some patients but resolves without permanent sequelae 1
Long-term outcomes: Significantly lower rates of anal stenosis and recurrent fissures at 6 and 24 months compared to hemorrhoidectomy alone 1
Critical Pitfalls to Avoid
Never perform anal dilatation as an adjunct to either procedure, as it causes sphincter injuries and results in 52% incontinence rate at long-term follow-up 2.
Do not ignore grade 3 bleeding hemorrhoids while performing sphincterotomy alone, as this leaves the patient with ongoing bleeding and prolapse requiring a second procedure 2.
Avoid excessive sphincter division, as hemorrhoidectomy alone carries up to 12% risk of sphincter defects, and adding aggressive sphincterotomy increases incontinence rates 2.
Never use cryotherapy, as it causes prolonged pain, foul-smelling discharge, and requires more additional therapy 2.
Special Considerations for Your Patient
Given the history of posterior anal fissure, previous fissurectomy, internal hemorrhoidectomy, and lateral internal sphincterectomy, this patient requires careful assessment:
Verify sphincter integrity with anorectal manometry before any additional sphincter surgery, as previous sphincterotomy may have already compromised function 3
Consider that recurrent symptoms may represent inadequate initial sphincterotomy rather than new pathology requiring additional surgery 3
Evaluate for anal stenosis, which occurs in patients with previous hemorrhoidectomy and may benefit from combined revision surgery 3
Postoperative Management
Emphasize high-fiber diet (25-30g daily) and adequate hydration to prevent constipation and straining, which could compromise healing of both surgical sites 2, 6.
Postoperative ablution with mild antiseptic added to plain water is adequate for maintaining hygiene and promoting healing 4.
Most patients return to normal activities within 4-6 weeks without early or late complications when proper technique is employed 3.